'Checklist' may help distinguish overlapping features of COVID-19, giant cell arteritis
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Giant cell arteritis and COVID-19 both feature headache, fever, elevated C-reactive protein and cough as symptoms, whereas jaw claudication, visual loss and platelet and lymphocyte counts may be more discriminatory, according to findings.
“GCA is a medical emergency and needs urgent assessment by a specialist such as a rheumatologist or ophthalmologist,” Sarah L. Mackie, PhD, of the University of Leeds, told Healio Rheumatology. “Headache is a very common presenting symptom of GCA, but during the pandemic of 2020 we discovered that headache is also a common early symptom of COVID-19. In the U.K., headache is still not one of the ‘official’ symptoms that enables people to access community COVID testing. During the first peak of the pandemic, we had several patients referred to us with suspected giant cell arteritis who actually had COVID-19.”
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“Our first line test to investigate for GCA, after blood tests, is temporal artery ultrasound,” she added. “This ultrasound scan requires close proximity between patient and sonographer for half an hour or more. The scan takes place in a small room containing many surfaces which take time to deep clean. It is not an ideal situation if the patient actually has COVID-19. I wanted to create a checklist for members of the team to help them make a clinical judgement as to how likely a patient was to have GCA versus COVID-19.”
To identify the shared and distinct features of GCA and COVID-19, and ultimately prevent diagnostic errors, Mehta and colleagues conducted two systemic literature reviews focusing on symptom frequency. For the GCA review, the researchers searched PubMed, Embase and the Cochrane Database of Systematic Reviews to identify studies recruiting consecutive patients with suspected GCA. This review yielded 1,666 results, of which 35 studies were included for analysis.
Meanwhile, for the COVID-19 review, Mehta and colleagues identified all cohorts or case series published between Jan. 1, 2020, and April 5, 2020, that described patients diagnosed with the disease. Retrospective cases series with fewer than 50 patients and those in which all patients died, were in the intensive care unit or demonstrated a particular comorbidity, such as cancer, were excluded. The search included PubMed, Embase and the Cochrane Database of Systematic Reviews. In all, 211 COVID-19 studies were identified. Of these, 29 studies, with a total of 5,623 patients, were included for analysis.
For each included publication, the researchers noted the reported frequencies of each symptom, sign, or laboratory feature. In addition, they used medians and ranges to summarize frequencies in each disease.
According to the researchers, headache was common in GCA, with a frequency of 66%, but also observed in COVID-19, with a frequency of 10%. However, jaw claudication or visual loss — seen in 43% and 26% of GCA cases, respectively — were generally not demonstrated in COVID-19. Both GCA and COVID-19 featured fatigue — 38% compared with 43%, respectively — and elevated inflammatory markers, including C-reactive protein elevated in 100% of GCA cases and in 66% of COVID-19 cases. Platelet count, however, was elevated in 47% of GCA cases but only in 4% of patients with COVID-19.
Patients with COVID-19 commonly demonstrated cough — 63% of cases — and fever — 83% of cases— whereas those with GCA experienced these symptoms less often, with frequencies of 12% for cough and 27% for fever.
Gastrointestinal upset was reported in 8% of COVID-19 and in 4% GCA cases. Meanwhile, lymphopenia was present in 53% of patients with COVID-19, compared with 2% of GCA cases. Loss of change in sense of smell or taste has been reported in GCA but their frequency is unclear, the researchers wrote.
“We are still using the checklist in our clinical practice currently in Leeds,” Mackie said. “It does not determine clinical management, but it encourages a systematic approach to eliciting information relevant to clinical decision-making, is a good aid to communication between team members and forms a record of what decision was made at the time of assessment based on information available. We wanted to share our learning in case others might want to adapt this approach in their own centers.”
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